Intubation in trauma patient stem

[anbuitachi]

Saw a bunch of you recommend UBP for oral board so i decided to take a look... yet the first stem they gave i already have some questions about either the book or my ability to practice anesthesia. Is the oral board really expecting me to give answers like this?

stem: super morbid obese 5'7 180kg. 22 yr old in vehicle trauma gcs 9, with signs of basilar fracture, facial fracutre, multiple loose teeth, tachy 130s, bp 170s, sat 96% on non rebreather, 33C temp.

Q: Patient becoming more combative, how would you intubate.

I thought i would just say something like induce propofol, succ. and intubate with video laryngoscope with C collar in place or remove and apply manual inline stabilization, with difficult airway/trach equipment on standby.

UBP response.: awake intubation unlikely to succeed due to trauma and combative patient. thus, have difficult airway equipment, including trach set, surgeon at bedside and ready to perform trach, sit patient at 30 degrees to facilitate intubation and improve ventilation/decrease regurgitation, titrate ketamine to maintain spontaneous respiration, remove C collar, maintain manual inline stabilization and apply cricoid pressure, then perform laryngscopy.

Is this the type of answers we are supposed to give on the boards? do you think i would have failed with my response of paralyzing with sux in this obese patient with trauma?

Also do you also intubate at 30 degrees? I sometimes do so for preoxygenation but i usually lay them flat for intubation.. isnt it harder to intubate at 30 degrees than supine? and although it may decrease risk of regurg food contents up, if it does it has increased risk of aspiration..

---

Members don't see this ad.

 

[deleted697535]

stem: super morbid obese 5'7 180kg. 22 yr old in vehicle trauma gcs 9, with signs of basilar skull fracture, multiple loose teeth

I thought i would just say something like induce propofol, succ. and intubate with video laryngoscope

do you think i would have failed with my response of paralyzing this obese patient with trauma?

Well if you said 'something like prop sux tube' you're going to struggle when they inevitably tell you grade 4 view, or blood soiling vl etc.

With your answer you havent in any way informed the examiners that this dude could die during intubation. You only have a plan A.

No plan b. No conflicts.

This dude has 4 obvious conflicts full stomach, tbi, difficult airway and supermorbid obese

There is no exact right way to do it, but there are many wrong ways. And the exams are designed to never have a 100% correct way.

All you have to do is inform the examiners you understand the conflicts and are reasonably safe.

 

[dchz]

There is no exact right way to do it, but there are many wrong ways. And the exams are designed to never have a 100% correct way.

All you have to do is inform the examiners you understand are are reasonably safe.

That's what I aim for.

edit: corrected spelling.

 

[anbuitachi]

Well if you said 'something like prop sux tube' you're going to struggle when they inevitably tell you grade 4 view, or blood soiling vl etc.

With your answer you havent in any way informed the examiners that this dude could die during intubation. You only have a plan A.

No plan b. No conflicts.

This dude has 4 obvious conflicts full stomach, tbi, difficult airway and supermorbid obese

There is no exact right way to do it, but there are many wrong ways. And the exams are designed to never have a 100% correct way.

All you have to do is inform the examiners you understand are are reasonably safe.

Prop sux tube is not the safest.

i did mention my plan would have difficult airway equipment including trach ready. that would be plan B if cant intubate/ventilate.
do you always sit your patients up 30% during intubating full stomach patients? is this even evidence based? i have never done this before
do you always avoid sux during TBi? If this guy had bmi of 20, would you give double dose roc instead? or would you still proceed with no paralytics?

 

[deleted697535]

Sitting patients up etc is just window dressing bs these prep groups put in to seem smart. It's irrelevant and I agree has no good evidence.

Potentially they are trying to create something like a troop pillow. Then I'd probably agree with it but is a combatitive patient going to tolerate that?

It's definitely not a bad idea for ease of bvm or for tbi purposes.

But to. Answer your q no I don't do it for all rsi.

Sux can be used in tbi but if you'd don't acknowledge that it does raise icp you can be in trouble when his pupils blows post intubation.

High dose roc can be used but then will you have 16mg*180 available?

As I say there is no 100% right and to these stems, you just have understand the conflicts and mention them

For this guy I'd probably do
1 precedex afoi plan a, in the or with the troop pillow, manitol and pressors. Surgeon prepared for front of neck and neck already marked.
Plan b would be spont vent glide with ketofol. Plan c ketofol sux tube. Rescue plans for all above 2nd Gen lma or surgical aw

 

[deleted697535]

That's what I am for.

Sorry what?

 

[deleted697535]

Prop sux tube is not the safest.

Edit - prop sux tube is often the safest. But it is also the answer of a novice who sees no inherent danger in it. You need to obviously differentiate yourself to a novice tipping your cap to all the conflicts. Then do prop sux tube.


Edit - i dont really like ubps plan for ketamine only spont vent VL in a tbi patient. Ketamine as a sole agent has negative psych effect in at least 10% probably 33% (dude is already combatative), it definitely incr CMRO2 and CBF as a sole agent, and its a ****ty sole agent to allow you do spont vent DL.
I also do not agree with their assertion he will unlikely tolerate awake intubation. They seem to be confused that awake intubation must be the only way to use a fibreoptic . There are many ways to use a fibreoptic scope with sedation/anesthesia. For them to automatically discard the fibrescope just cause hes combative is silly.

Id much prefer midaz/fent or precedex FOI. Its far gentler than doing spont vent DL with ketamine only?. Has anyone ever done that??
Ive done plenty of spont vent DL and VLs but not with ketamine only. You need loads of topicalisation that i really doubt this dude will tolerate.

So ubps answer isnt that great either

 

[deleted697535]

For these stems there are only about 40 common conflicts.
We used to sit down and put them together in various combos.
You can only have 3 or so. Max per stem

So swap out supermorbid obese and put in tight mitral stenosis there.
Then put in crest with pulm htn and microstomia instead of mitral stenosis etc

 

[Justice4all]

No matter what you say, the examiners will always throw another curve ball to see how you think on your feet. Just don't be too rigid in your responses.

 

[vector2]

Saw a bunch of you recommend UBP for oral board so i decided to take a look... yet the first stem they gave i already have some questions about either the book or my ability to practice anesthesia. Is the oral board really expecting me to give answers like this?

stem: super morbid obese 5'7 180kg. 22 yr old in vehicle trauma gcs 9, with signs of basilar fracture, facial fracutre, multiple loose teeth, tachy 130s, bp 170s, sat 96% on non rebreather, 33C temp.

Q: Patient becoming more combative, how would you intubate.

I thought i would just say something like induce propofol, succ. and intubate with video laryngoscope with C collar in place or remove and apply manual inline stabilization, with difficult airway/trach equipment on standby.

UBP response.: awake intubation unlikely to succeed due to trauma and combative patient. thus, have difficult airway equipment, including trach set, surgeon at bedside and ready to perform trach, sit patient at 30 degrees to facilitate intubation and improve ventilation/decrease regurgitation, titrate ketamine to maintain spontaneous respiration, remove C collar, maintain manual inline stabilization and apply cricoid pressure, then perform laryngscopy.

Is this the type of answers we are supposed to give on the boards? do you think i would have failed with my response of paralyzing with sux in this obese patient with trauma?

Also do you also intubate at 30 degrees? I sometimes do so for preoxygenation but i usually lay them flat for intubation.. isnt it harder to intubate at 30 degrees than supine? and although it may decrease risk of regurg food contents up, if it does it has increased risk of aspiration..

Stick with your original plan to prop/sux this pt while stating that if difficult you have fiberoptic, LMA, airway cart, and surgeon/trach in room for backup. UBP will go into some thorough but ultimately crazy responses which veer very far away from what you would do in real life. As someone said earlier, as long as you can verbalize that you've thought about the pros/cons of your choice, you'll be fine.

In the case of this stem, think about it....IRL, how often are you unable to secure the ETT just because someone is fat? Is there some epidemic of trachs going on in the bariatric gastric sleeve room? Nope. VL with hyperangulated blades have made failed intubation in the setting of morbid obesity (with no other severe difficult airway predictors) almost non-existent. Your examiners presumably have some clinical experience and they know just as well as you that glidescopes and mcgraths have been gamechangers.

 

[deleted547339]

What is y’all a deal with the trach? Both in EM and CCM I was taught that a cric is your go to emergent surgical airway - I am comfortable doing a bedside perc trach, but if the wheels fall off I’m cutting the neck with the intention of putting a bougie then some sort of airway appliance through the cric.

 

[ethilo]

I just took the exam a few months ago and passed, I used UBP to study.

Overall, UBP purposefully creates heinous scenarios that seem impossible and are riddled with everything working against you. This is of course, by design, as they explain in their orientation pages of the books. Though it's a bit ridiculous of a scenario, it creates plenty of discussion points for you to work through with your study partner.

When you get to the actual exam, they ultimately want to pass a person that meets the quota for what they would want in a US board certified anesthesiologist. What this means is they are going to put you in a position of a rock and a hard place and force you to make a decision that WILL have consequences. a board certified anesthesiologist will be faced with tough decisions and will be expected to MAKE decision. Since there's no purely right or wrong answer you need to demonstrate that you at least understand the possible consequences and that you can do something about it when it happens.

 

[ethilo]

I guess what I'm saying is that prop sux tube is an acceptable answer, just make sure to demonstrate to them that you are aware of the potential consequences of your decision and you have a plan to address those consequences when/if they come up

 

[Radetzky]

Huh who the hell would do awake ketamine intubation in a TBI pt?

While the evidence is all retrospective, there does seem to be sufficiently convincing (at least for me) evidence that sux is associated with worse outcome in RSI in the setting of TBI.

 

[deleted697535]

What is y’all a deal with the trach? Both in EM and CCM I was taught that a cric is your go to emergent surgical airway - I am comfortable doing a bedside perc trach, but if the wheels fall off I’m cutting the neck with the intention of putting a bougie then some sort of airway appliance through the cric.

Sorry, what?
What does your first sentence mean?
What is an emergent surgical airway?

We are not talking about what happens in Emerg on some random night.

We are talking about how to verbalize multiple anesthetic plans for a complex patient in under 2 minutes to the level of a staff anesthiologist.

We all know das/Asa difficult aw algorithms. We are trying to stay very far away from them.

If your plan to pass the exam is to go straight to surgical airway in a 180kg trauma patient then you probably won't do well.

It irrelevant what you think you are comfortable with. This is examsmanship

 

[deleted697535]

Stick with your original plan to prop/sux this pt while stating that if difficult you have fiberoptic, LMA, airway cart, and surgeon/trach in room for backup. UBP will go into some thorough but ultimately crazy responses which veer very far away from what you would do in real life. As someone said earlier, as long as you can verbalize that you've thought about the pros/cons of your choice, you'll be fine.

In the case of this stem, think about it....IRL, how often are you unable to secure the ETT just because someone is fat? Is there some epidemic of trachs going on in the bariatric gastric sleeve room? Nope. VL with hyperangulated blades have made failed intubation in the setting of morbid obesity (with no other severe difficult airway predictors) almost non-existent. Your examiners presumably have some clinical experience and they know just as well as you that glidescopes and mcgraths have been gamechangers.

You guys are funny. The act of putting the tube in is relatively easy!

What about sux in tbi? Any issues there? Or propofol in a supermorbid obese tachycardic trauma patient. What dose are you going to use? Do you have any concerns over doing rsi propofol dose in a shocked patient?

Because I do.


This hypothetical patient is not just fat. We'll never know the actual view but chipped teeth, emergent out of or setting with cspine collar in place. Personally I wouldn't rsi him in real life unless I absolutely had to. If he was mp1 with huge mo and teeth chipped in such a way to help view as opposed to hinder it then I'd rsi him. But mp4 and reasonably full dentition forget it. Afoi midaz fent Lido. Easy.

 

[AdmiralChz]

What is y’all a deal with the trach? Both in EM and CCM I was taught that a cric is your go to emergent surgical airway - I am comfortable doing a bedside perc trach, but if the wheels fall off I’m cutting the neck with the intention of putting a bougie then some sort of airway appliance through the cric.

No real “deal” against a trach, but we have enough good equipment, technology, knowledge and skills to secure airways without making a surgical incision on the neck. In 1990 this wasn’t as much the case but since then we have excellent LMAs, solid fiber optic devices and better drugs (Precedex, in the right hands). It’s a more elegant and straightforward solution to a difficult airway to a slash and dash approach.

Also, today’s CCM education (rightfully so) is de-emphasizing crics mirroring that of anesthesia education.

 

[deleted547339]

Sorry, what?
What does your first sentence mean?
What is an emergent surgical airway?

We are not talking about what happens in Emerg on some random night.

We are talking about how to verbalize multiple anesthetic plans for a complex patient in under 2 minutes to the level of a staff anesthiologist.

We all know das/Asa difficult aw algorithms. We are trying to stay very far away from them.

If your plan to pass the exam is to go straight to surgical airway in a 180kg trauma patient then you probably won't do well.

It irrelevant what you think you are comfortable with. This is examsmanship

No real “deal” against a trach, but we have enough good equipment, technology, knowledge and skills to secure airways without making a surgical incision on the neck. In 1990 this wasn’t as much the case but since then we have excellent LMAs, solid fiber optic devices and better drugs (Precedex, in the right hands). It’s a more elegant and straightforward solution to a difficult airway to a slash and dash approach.

Also, today’s CCM education (rightfully so) is de-emphasizing crics mirroring that of anesthesia education.

Sorry - I must have not been clear. I wasn’t commenting on your airway decision making. What I meant was that I know a lot of surgeons and anesthesiologists who consider a trach an appropriate emergent surgical airway; whereas I’ve always been taught that a cric is the emergent airway of choice. It wasn’t a question of when to pull the trigger or what other modalities to use first, it was strictly a question of why some are taught to cut an inch or two lower than others.

 

[deleted697535]

Sorry - I must have not been clear. I wasn’t commenting on your airway decision making. What I meant was that I know a lot of surgeons and anesthesiologists who consider a trach an appropriate emergent surgical airway; whereas I’ve always been taught that a cric is the emergent airway of choice. It wasn’t a question of when to pull the trigger or what other modalities to use first, it was strictly a question of why some are taught to cut an inch or two lower than others.

Ok well to respond to that you have to tease out why you're intubating in the first place.

Not all traumas are the same as you obviously know. But a burn is very different to a tracheobronchial disruption or a lefort3 vs a tongue laceration.

This case here above is none of those. He's a possible tbi that needs sedation analgesia investigation and the tube just facilitates that. His oxygenation is ok for now.


Think of all the reasons for a tube in trauma. There's the 6 immediate threats to life. All require diff aw mgt. Would you trache a tamponade? No. Neither would you trache a
Tracheobronch disruption. That's 100% a hard fail.

Would you rsi a bronchopleural fistula? Also a hard fail.

So there no is no magic 1 'emergent' airway of choice for trauma . There are many ways to suit the particular pathology the patient has.

Some may be straight to surgical airway but not many. Probably only 1 situation would lead me straight to that tbh

 

[vector2]

You guys are funny. The act of putting the tube in is relatively easy!

What about sux in tbi? Any issues there? Or propofol in a supermorbid obese tachycardic trauma patient. What dose are you going to use? Do you have any concerns over doing rsi propofol dose in a shocked patient?

Because I do.


This hypothetical patient is not just fat. We'll never know the actual view but chipped teeth, emergent out of or setting with cspine collar in place. Personally I wouldn't rsi him in real life unless I absolutely had to. If he was mp1 with huge mo and teeth chipped in such a way to help view as opposed to hinder it then I'd rsi him. But mp4 and reasonably full dentition forget it. Afoi midaz fent Lido. Easy.

Sux and increased ICP to the point of worsening TBH or intracranial hypertension is a myth, and even though that's been relatively known for 20 years the legend somehow still lives on.

But you know what really increases ICP? Your half-assed attempt to effectively topicalize, sedate, and instrument the airway of an altered GCS 9 tachycardic and hypertensive whale who's satting 96 on 15L NRB mask. Effective awake FOI topicalization takes time, patience, and involves the patient being able to follow directions, so shooting some 4% into this guys mouth and nares and trying to snow him out with some midaz and fent without causing too much respiratory depression (and increased PaCO2/hypoxemia) or bucking (with a 30 point rise in abdominal pressure/ICP) is a "bad" plan.

 

[vector2]

Sorry - I must have not been clear. I wasn’t commenting on your airway decision making. What I meant was that I know a lot of surgeons and anesthesiologists who consider a trach an appropriate emergent surgical airway; whereas I’ve always been taught that a cric is the emergent airway of choice. It wasn’t a question of when to pull the trigger or what other modalities to use first, it was strictly a question of why some are taught to cut an inch or two lower than others.

I think most of us are just being loose with terminology and simply mean surgical airway, not specifically advocating for a trach over cric (although to be fair, many "cric" punctures or neck slashes are probably not infrequently going through rings instead of the cricothyroid membrane)

 

[deleted547339]

I think most of us are just being loose with terminology and simply mean surgical airway, not specifically advocating for a trach over cric (although to be fair, many "cric" punctures or neck slashes are probably not infrequently going through rings instead of the cricothyroid membrane)

Ah. That makes sense. Obviously, we all do and work with patients that have trachs approximately 100x more often than crics - so I see how a “trach” could be a colloquial term for a cric in that setting.

 

[deleted697535]

Sux and increased ICP to the point of worsening TBH or intracranial hypertension is a myth, and even though that's been relatively known for 20 years the legend somehow still lives on.

But you know what really increases ICP? Your half-assed attempt to effectively topicalize, sedate, and instrument the airway of an altered GCS 9 tachycardic and hypertensive whale who's satting 96 on 15L NRB mask. Effective awake FOI topicalization takes time, patience, and involves the patient being able to follow directions, so shooting some 4% into this guys mouth and nares and trying to snow him out with some midaz and fent without causing too much respiratory depression (and increased PaCO2/hypoxemia) or bucking (with a 30 point rise in abdominal pressure/ICP) is a "bad" plan.

I can see exactly how this stem goes. I had one similar!

Ok you have pushed prop and sux. Dl reveals grade 4 view. Bvm is impossible. How would you like to proceed now vector? Spo2 is now 88

 

[vector2]

Lol. Easy up there man.
My plan is fine. It's safe. It will work well. It's the ubp answer but more refined probably. I still have a plan b and c to fall back on. That's the key to the exam, which is what this thread is.


Yours has many holes in it. It might work. Plan b is I assume surgical airway in said whale. I wonder what his co2 will be at the end of that procedure?? 200?

I'd prefer to have my conversation with the examiners than yours.

But I do agree your way will also probably work in real life and probably pass the exam too.

You're saying my plan "might work" as if the odds of a failed first pass video intubation are particularly high. As I said before, in the absence of other difficult airway predictors, securing the airway of a morbidly obese person is easy with VL, hence why I've never had a failed morbidly obese airway in the last 3 years in my center which does high volume, huge BMI bariatric surgery.

Your plan is not fine and it's probably not safe, especially if escalating doses of midaz and fent are being required. It's worse than the UBP answer because the UBP answer is relying on dissociation and analgesia with ketamine to prevent the patient from 1. having a massive sympathetic response to laryngoscopy 2. having a massive combative response to airway instrumentation 3. respiratory depression with the accompanying ICP rise. Your plan does none of those things because you're not going to be able to effectively topicalize and midaz/fent are not particularly good for altered, combative, morbidly obese pts unless you have totally snowed them to the point of obstruction/apnea.

I can see exactly how this stem goes. I had one similar!

Ok you have pushed prop and sux. Dl reveals grade 4 view. Bvm is impossible. How would you like to proceed now vector? Spo2 is now 88

I've passed my orals. Let me know when you're done with SOE and FRCA.

 

[deleted697535]

My initial plan was precedex actually. And it's 100% fine. Midaz fent crept in there somehow but my plan was precedex from post 5. My exam answer for this type of case was precedex. It went fine. So if I say precedex not midaz fent is that ok?

In the absense of other difficult aw indicators? Man come on. Dude is post trauma in a c collar with broken teeth!?! Are any of these lighting up any signs of difficult airway?

Is this a joke? You are attempting to use elective study to prove that emergent trauma patient with chipped teeth and c collar is an easy intubation. Wow

I'm out.

 

[deleted547339]

hence why I've never had a failed airway in the last 3 years in my center which does high volume, huge BMI bariatric surgery.

That must be nice. Our fat people stay fat, lol.

 

[vector2]

My initial plan was precedex actually. And it's 100% fine. Midaz fent crept in there somehow but my plan was precedex from post 5. My exam answer for this type of case was precedex. It went fine. So if I say precedex not midaz fent is that ok?

In the absense of other difficult aw indicators? Man come on. Dude is post trauma in a c collar with broken teeth!?! Are any of these lighting up any signs of difficult airway?

Precedex might help from the respiratory depression standpoint, but again, it's not going to be a sufficient sole sedative for an altered GCS 9 pt who's not going to comply with topicalization instructions.

As far as the c-collar, it can come off, but even if it couldn't one of the great advantages of hyperangulated VL blades is that neck positioning isn't absolutely required. And what are you getting at with the broken teeth as far as difficult airway, since being edentulous makes intubation easier? Bloody mouth? Uhhh....consider how that's going to affect your fiber scope vs my laryygoscope + yankauer suction.

 

[vector2]

Long story short to OP before we derail too much- if in your residency training you have been exposed to a large variety of pathologies and techniques, have confidence in that training and don't wander into unfamiliar territory because you think that's the "book answer" the examiners want to hear.

 

[nimbus]

Bloody mouth? Uhhh....consider how that's going to affect your fiber scope vs my laryygoscope + yankauer suction.

Topicalizing that bloody mouth full of broken teeth is just a fantasy too.

 

[dhb]

Also do you also intubate at 30 degrees?

I like it. With the patient sitting up the axis of your eye sight is more inline with the patient's glottis than when they are laying flat. If i'm intubating in a bed or strecher i'll leave them sitting but in the OR i don't bother to raise the back of the table.

 

[Arch Guillotti]

Topicalizing that bloody mouth full of broken teeth is just a fantasy too.

Yep

 

[T-burglar]

I just want to chime in and say there is nothing in the stem to suggest intracranial hypertension so that shouldn’t be a factor in anyeones decision making

 

[T-burglar]

also people saying that we should just forget about the cric - have a look at the closed claims database. Reality begs to differ with your idea that technology makes this technique obsolete. In reality people flounder and fail to secure the airway until cardiac arrest has occurred. I advocate the approach of numbing, sterilizing and pre marking the anterior neck in any case where it’s a remote possibility because it gets you mentally ready to pull the trigger when it’s tjme to. Put on your big boy pants and save a life.

And I’ve only cricd one person in my career.

 

[vector2]

I just want to chime in and say there is nothing in the stem to suggest intracranial hypertension so that shouldn’t be a factor in anyeones decision making

The stem doesn't explicitly say ICH, but it also doesn't provide or hint toward any other likely causes (alcohol breath, positive tox) of an altered sensorium, GCS 9, combative state other than head trauma. And even if ICH is ruled out, we still want intubation to be smooth when the patient is at high risk for various facial/cerebral bleeding, CSF leaks, etc.

 

[AdmiralChz]

also people saying that we should just forget about the cric - have a look at the closed claims database

Failed airway cases, particularly in the obstetric population, has plummeted in number from the 90s to 2010s. This was evaluated just this past year, I’ll find the link.

I’m not saying forget about it, but doing one should be a once-in-a-career (or none) occurence.

 

[anbuitachi]

thanks for the responses. glad to see the differences in opinion!

What about cricoid? if this was the boards, would you say ' take off C collar and apply cricoid'? in real life i would consider intubating with C collar in place. on exams they may want me to take it off to apply manual in line, and cricoid im guessing. also easier to access neck if emergency arise . i guess the latter is more defensible

 

[WholeLottaGame7]

My initial plan was precedex actually. And it's 100% fine. Midaz fent crept in there somehow but my plan was precedex from post 5. My exam answer for this type of case was precedex. It went fine. So if I say precedex not midaz fent is that ok?

In the absense of other difficult aw indicators? Man come on. Dude is post trauma in a c collar with broken teeth!?! Are any of these lighting up any signs of difficult airway?

Is this a joke? You are attempting to use elective study to prove that emergent trauma patient with chipped teeth and c collar is an easy intubation. Wow

I'm out.

Precedex on an altered 180kg 22yo sounds like a horrible plan. Precedex is a great drug for keeping calm people calm, i.e. elective FOIs. It's terrible for calming down super agitated adults (unless you're planning on using like 200mcg of precedex). Also, your choices are to give boluses over 15-30min (not an option), or if you slam it in you're going to crush the HR and jack the BP through the roof, and then you're going to have to sort out whether it's just the precedex bolus or they're herniating.

You're going to get much better "sedation" with 400-500 of ketamine. The dissociation is only a problem if you stop partway.

And you know what else is bad for TBI? Hypoxic brain injury from not securing the airway in a timely fashion.

Yeah, the oral board examiner is going to throw you a curveball if you say prop/sux/tube. But they're also going to throw you a curveball if you try to do an "awake" FOI on this guy. The OP's original plan is not unreasonable as long as he goes through the difficult airway progression in a timely fashion.

This scenario is going to wind up with a surgical airway regardless, so just be ready to go there quickly.

What's the joke with oral boards? Just call for help as soon as you walk in the room and do elective awake trachs and put defib pads on everyone?

 

[dhb]

And I’ve only cricd one person in my career.

Humblebrag

 

[deleted697535]

Precedex on an altered 180kg 22yo sounds like a horrible plan. Precedex is a great drug for keeping calm people calm, i.e. elective FOIs. It's terrible for calming down super agitated adults (unless you're planning on using like 200mcg of precedex). Also, your choices are to give boluses over 15-30min (not an option), or if you slam it in you're going to crush the HR and jack the BP through the roof, and then you're going to have to sort out whether it's just the precedex bolus or they're herniating.

You're going to get much better "sedation" with 400-500 of ketamine. The dissociation is only a problem if you stop partway.

And you know what else is bad for TBI? Hypoxic brain injury from not securing the airway in a timely fashion.

Profound. I had never heard that before. Thank you.
Ketamine as a sole agent in tbi is a great choice. especially almost 4mg/kg. I agree

 

[Mman]

a few random thoughts on the topic

1) I always sit the fat ones up for the duration of the airway. Helps preoxygenation, makes ventilation easier, and usually helps with laryngscopy.
2) sux does not cause a problem in ICP patients. It just doesn't. Being hypercarbic for an extended period of time does hurt them. If you can put a tube in faster with sux, then by all means that is the best thing to use.
3) video laryngscopy is a lifesaver for both morbid obesity and cervical injuries (and the combination). Absent some other pathology (radiation, etc) if they can open their mouth wide enough to fit the blade in there is way under 1% chance you can't get the tube in.

 

[anbuitachi]

a few random thoughts on the topic

1) I always sit the fat ones up for the duration of the airway. Helps preoxygenation, makes ventilation easier, and usually helps with laryngscopy.
2) sux does not cause a problem in ICP patients. It just doesn't. Being hypercarbic for an extended period of time does hurt them. If you can put a tube in faster with sux, then by all means that is the best thing to use.
3) video laryngscopy is a lifesaver for both morbid obesity and cervical injuries (and the combination). Absent some other pathology (radiation, etc) if they can open their mouth wide enough to fit the blade in there is way under 1% chance you can't get the tube in.

my experience with intubations in back up patients has always been extension of the neck during positioning/laryngoscopy. otherwise their big head blocks my view because i cant see the mouth without bending my back/neck above them so now i'm not standing straight anymore. and its harder to lift up because the vector is now less perpendicular than if patient was flat.

see picture below, to achieve adequate positioning, this patients neck is extended, which id want to avoid if unstable c spine

 

[Robotic Wis-Hipple]

The entire point of the stem, and stems of the oral board is to show you that there is no good way. Each plan has downsides, each plan has an easily deployed curveball waiting. The test is testing your knowledge while also testing your decision making in the setting of no good answers. So pick your way and preemptively defend it by acknowledging the potential downsides as well as showing that you’ve considered other options and feel as though this way is your highest/safest yield.

Imo, coming off so sure your way is perfect is just as bad as coming off scared to death of all of the options. Prep to find the balance between cowboy and scaredy cat.

And in regards to UBP, every MP3 or worse gets an AFOI, every EF <40 gets preinduction a-lines, etomidate, and a PAC, etc. I think you aknowledge these options but if you deploy them every stem you come off as the scaredy cat.

 

[Mman]

my experience with intubations in back up patients has always been extension of the neck during positioning/laryngoscopy. otherwise their big head blocks my view because i cant see the mouth without bending my back/neck above them so now i'm not standing straight anymore. and its harder to lift up because the vector is now less perpendicular than if patient was flat.

see picture below, to achieve adequate positioning, this patients neck is extended, which id want to avoid if unstable c spine

View attachment 295138

when I say sit up, I usually just mean reverse T-berg on the bed. Occasionally just back up. If steep enough I just have to stand on some steps to get high enough but it always makes it easier than somebody who is just supine. The fat tissue doesn't fall back in their pharynx as much.

 

[Morzh]

Without sarcasm, may be a great scenario for retrograde wire! You'll already have angiocath in the trachea to boot, if all else fails

 

[pgg]

I'm just here to pile on and say that trying to use Precedex to AFOI a combative GCS 9 trauma patient with a bloody mouth full of broken teeth is straight up ridiculous and I'd consider it a kill error, see you next year, thanks for coming out.

 

[IlDestriero]

Well if you said 'something like prop sux tube' you're going to struggle when they inevitably tell you grade 4 view, or blood soiling vl etc.

With your answer you havent in any way informed the examiners that this dude could die during intubation. You only have a plan A.

No plan b. No conflicts.

This dude has 4 obvious conflicts full stomach, tbi, difficult airway and supermorbid obese

There is no exact right way to do it, but there are many wrong ways. And the exams are designed to never have a 100% correct way.

All you have to do is inform the examiners you understand the conflicts and are reasonably safe.

And with whatever approach you choose, there will be some reason you can’t do it or catastrophe and it has nothing to do with your plan (assuming it was safe). It’s just part of the exam. So don’t get flustered, just work the problem(s) and keep on trucking.

 

[Mman]

And with whatever approach you choose, there will be some reason you can’t do it or catastrophe and it has nothing to do with your plan (assuming it was safe). It’s just part of the exam. So don’t get flustered, just work the problem(s) and keep on trucking.

I just assume on every airway line of questioning you are either going to end up doing a cric or going on ecmo. The whole point is just to show your thought process and ability to calmly explain your rationale as the patient spirals towards death.

 

[coffeebythelake]

I just assume on every airway line of questioning you are either going to end up doing a cric or going on ecmo. The whole point is just to show your thought process and ability to calmly explain your rationale as the patient spirals towards death.

I had a similar stem for my oral boards. I said have emergency airway equipment and then I went for prop/suxx/tube. Hahah. Basically controlled the narrative and went down the difficult airway algorithm and CICV scenario. Still passed.

 

[Mman]

I had a similar stem for my oral boards. I said have emergency airway equipment and then I went for prop/suxx/tube. Hahah. Basically controlled the narrative and went down the difficult airway algorithm and CICV scenario. Still passed.

yes, you have to know how to proceed when the inevitable failures happen but that doesn't mean that you awake FOI every scenario. Just be ready in case they make whatever you do fail.

 

[WholeLottaGame7]

Profound. I had never heard that before. Thank you.
Ketamine as a sole agent in tbi is a great choice. especially almost 4mg/kg. I agree

Everything is bad for TBI. Your plan was bad, my plan was bad, the prop/sux/tube plan was bad. Just understand what makes the plans bad, and choose the one you can execute least badly.

Maybe you're a wizard with precedex, or maybe you're just an altered/obese soothsayer, I dunno. Maybe for you, your way is the fastest.

I'm just explaining what my (and it appears others') experience with using precedex in the scenario you describe has been.